Cost-Sharing Limits; Provider Discrimination FAQ Released

On May 26, 2015, federal agencies, including the Department of Labor (DOL), issued a short five-question FAQ on two PPACA-related issues: limitations on cost-sharing and provider discrimination.

The FAQ further clarified that the self-only maximum annual limitation on cost sharing applies to each individual, regardless of whether the individual is enrolled in self-only coverage or coverage that is other than self-only (such as family). This echoes what all federal agencies have been stating on the topic. The FAQ further noted that this requirement applies to all non-grandfathered group health plans, and applies to plan or policy years that begin in or after 2016. This included non-grandfathered high deductible health plans (HDHPs).

The FAQ also confirmed that enforcement of PPACA's provider non-discrimination requirements is delayed so long as the plan or issuer is using in good faith a reasonable interpretation of the statutory provision, which states:

A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider's license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.

The agencies stated they are working with employers, plans, issuers, states, providers, and stakeholders to help them comply with nondiscrimination provisions and are working on further guidance.